ULTRASOUND CONSENT FORM

Gynecological (GYN) Ultrasound Information

An ultrasound has been ordered on you by your physician. There are many reasons that this diagnostic test may have been ordered. An evaluation of your pelvis that may include uterus, ovaries and adnexa will be performed. The quality of ultrasound examinations is extremely dependent on the equipment utilized, the sonographer doing the ultrasound, your body habitus, previous abdominal/pelvic surgeries and the physician who interprets your exam. Ultrasound examinations have never been shown to be harmful.
Failure to have this ultrasound exam may make it difficult for your physician to make a diagnosis and care for you in the best possible way. There may be abnormalities in your pelvis that may benefit from diagnosis and treatment. The utmost care and concern are given to you. Even so, ultrasound is not a perfect science and things can be missed or not seen depending on the position of your organs and your body composition. There are some abnormalities that are never seen with ultrasound.
I understand that ultrasound cannot see all things, but that it may be a very helpful tool to help manage my care. I have read this consent, fully understand the above information, and have had all my questions answered to my satisfaction.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Obstetrical Ultrasound Information

Your physician has requested that you undergo a diagnostic ultrasound. Simply stated, this procedure involves the transmission of sound waves reflected off your womb and fetus, which will be monitored and recorded digitally on or film to obtain information concerning your pregnancy. This test is believed to carry very little risk to you or your fetus (baby).

The standard ultrasound exam takes approximately 10 to 30 minutes to perform and may provide information concerning placental location, fetal position, multiple gestation (twins, etc.), approximate gestational age, and possible presence of certain gross fetal malformations. This test, however, is not definitive for the absence of fetal malformations, and despite a normal interpretation of the test, some babies are born with anomalies not identified by the examiner during the ultrasound study. Thus, although ultrasonography is a helpful diagnostic tool, it does not absolutely determine the absence of fetal defects. This type of exam is also done prior to performing genetic amniocentesis.

We welcome family members to observe these ultrasounds with you. You may bring children under the age of 12 to your anatomy ultrasound ONLY. This ultrasound will be done around 20 weeks of pregnancy. For the anatomy ultrasound, we ask that you bring no more than 3 people with you (including children). For all your other ultrasounds, you may bring up to two people with you (no children under the age of 12). Children MUST be accompanied by another adult to supervise them.

I understand that ultrasound cannot see all things, but that it may be a very helpful tool to help manage my care. I have read this consent, fully understand the above information, and have had all my questions answered to my satisfaction.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

3D/4D Ultrasound for Entertainment Purposes Only

I consent to have an elective 3D/4D ultrasound performed. I understand that the ultrasound is a Non-Diagnostic Ultrasound and Does Not provide measurements, dating or assesses for fetal anomalies. I have had a previous ultrasound performed. Further, I understand that payment is due and payable prior to the ultrasound ($150 for a 30-minute session). The required gestational age for fetal portraits is between twenty-eight (28) and thirty-four (34) weeks. I will receive a CD-ROM with moving images and still pictures. This CD will become my property as part of the fee paid. I will not hold LEON W. LEWIS MD., P.C. MD liable for any outcomes regarding this elective service. All my questions have been answered to my satisfaction and I understand the above information.

I have read this consent, fully understand the above information, and have had all my questions answered to my satisfaction.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.